Naive patients with CHB admitted to our hospital between January 2012 and April 2014 were evaluated retrospectively. The patients were allocated into one of two groups based on HBeAg-seropositivity status.

Results

Two hundred and fourteen patients were enrolled in the study. Of these 214 patients, 103 (48.1%) were HBeAg-positive and 111 (51.9%) were HBeAg-negative. In the HBeAg-positive group, positive correlations were found between histologic activity index (HAI) scores and ALT (t=3.3, r=0.31, p=0.001), AST (t=2.8, r=0.27, p=0.005) and HBV DNA load (t=2.5, r=0.24, p=0.014). Additionally, in this group, fibrosis scores had positive correlations with ALT (t=3.3, r=0.32, p=0.001) and AST (t=2.7, r=0.26, p=0.008). In the HBeAg-negative group, positive correlations were found between HAI scores and ALT (t=3, r=0. 28, p=0.003), AST (t=3, r=0. 28, p=0.003) and HBV DNA (t=5.3, r=0. 45, p=0). In this same group, fibrosis scores had a positive correlation with HBV DNA (t=2.2, r=0. 21, p=0.024). Multivariate logistic regression analysis showed a positive relationship between fibrosis and ALT in the HBeAg-positive group and a positive relationship between fibrosis and HBV DNA load in the HBeAg-negative group.

Conclusions

This study showed that HBV DNA load is an independent predictive factor for evaluating HAI and fibrosis in the HBeAg-negative group. Also, ALT is an independent predictive factor for evaluating fibrosis in the HBeAg-positive group.

With the end of UK military operations in Iraq and Afghanistan, it is essential that peacetime training of Defence Medical Services (DMS) trauma teams ensures appropriate future preparedness. A new model of pre-deployment training involves placement of formed military trauma teams into civilian trauma centres. This study evaluates the benefit of ‘live training during an exercise period’ (LIVEX) for DMS trauma teams.

Methods

A cross-sectional questionnaire-based survey of participants was conducted. Quantitative data were collected prior to the start and on the final day. Written reports were collected from the coordinators. Thematic analysis was used to identify emergent themes in a , qualitative analysis.

Results

Each team comprised 13 personnel and results should be interpreted with knowledge of this small sample size. The response rate for both the pre-LIVEX and post-LIVEX questionnaire was 100%. By the end of the week, 89% of participants (n=23) stated LIVEX was an ‘appropriate or very appropriate’ way of preparing for an operational role compared with 40% (n=9) before the exercise (p<0.01). However, completing LIVEX made no difference to participants' personal perception of their own operational preparedness. Thematic analysis suggested greater training benefit for more junior members of the team; from Regulars and Reservists training together; and from two-way exchange of information between DMS and National Health Service medical staffs.

Conclusions

Completing LIVEX made no statistically significant difference to participants' personal perception of their own operational preparedness, but the perception of LIVEX as an appropriate training platform improved significantly after conducting the training exercise.

Glutathione S-transferases are metabolic enzymes which are responsible for detoxification of endogenous (products of oxidative stress) as well as exogenous (drugs, pesticides, herbicides, environmental pollutants and carcinogens) products. Dysfunctional detoxification enzymes are responsible for the production of oxidative stress; a major contributor to the development of coronary artery disease (CAD).

Objectives

The present case-control study aimed to investigate the association of GSTT1 and GSTM1 gene polymorphisms with CAD.

Methods

In the present study, 200 patients diagnosed with CAD and 200 age, sex and population subgroup matched healthy controls were enrolled. The GSTT1 and GSTM1 gene polymorphisms were examined using multiplex PCR.

Breast cancers are heterogeneous, making it essential to recognise several biomarkers for cancer outcome predictions. Ki67 proliferation index and B cell lymphoma 2 (BCL2) proteins are widely used as prognostic indicators in many types of malignancies. While Ki67 is a marker of normal or tumour cell proliferation, BCL2 plays a central role in antiproliferative activities. A combination of these two biomarkers with contrary purposes can provide enhanced prognostic accuracy than an analysis using a single biomarker.

Methods

We evaluated Ki67 and BCL2 expression with 203 cases of breast cancer. The relative expression of each biomarker named as Ki67/BCL2 index was divided into two groups (low vs high) with the use of area under receiver operating characteristic curves.

Leadership skills directly correlate with the quality of technical performance of cardiopulmonary resuscitation (CPR) and clinical outcomes. Despite an improved focus on non-technical skills in CPR training, the leadership of cardiac arrests is often variable.

Aims

To assess the perceptions of leadership and team working among members of a cardiac arrest team and to evaluate future training needs.

Methods

Cross-sectional survey of 102 members of a cardiac arrest team at an Acute Hospital Trust in the UK with 892 inpatient beds. Responses sought from doctors, nurses and healthcare assistants to 12 rated statements and 4 dichotomous questions.

Results

Of 102 responses, 81 (79%) were from doctors and 21 (21%) from nurses. Among specialist registrars 90% agreed or strongly agreed that there was clear leadership at all arrests compared with between 28% and 49% of nurses and junior doctors respectively. Routine omission of key leadership tasks was reported by as many as 80% of junior doctors and 50% of nurses. Almost half of respondents reported non-adherence with Advanced Life Support (ALS) guidelines. Among junior members of the team, 36% felt confident to lead an arrest and 75% would welcome further dedicated cardiac arrest leadership training.

Conclusions

Leadership training is integrated into the ALS (Resus Council, UK) qualification. However, this paper found that in spite of this training; standards of leadership are variable. The findings suggest a pressing need for further dedicated cardiac arrest leadership training with a focus on improving key leadership tasks such as role assignment, team briefing and debriefing.

Inappropriate use of abbreviations and acronyms in healthcare has become an international patient safety issue. The aim of this study was to assess the knowledge of medical abbreviations and acronyms among residents of the department of medicine at a tertiary-care hospital.

Methods

Internal medicine residents (IMRs), subspecialty residents (SRs) and students were asked to complete a self-administered questionnaire which comprised standard abbreviations used in medicine and its various subspecialties. Scores obtained by the residents were classified into three categories: >70% correct answers; 50–69% correct answers; <50% correct answers.

Results

A total of 77 IMRs, SRs and medical students participated. Overall, good responses were achieved by 53 (68.8%), 16 (20.8%) attained satisfactory responses, and eight (10.4%) had unsatisfactory scores. The majority of SRs achieved good responses (19/22 (86%)), followed by IMRs (30/40 (75%)) and students (4/15 (26.7%)). Evaluation of their knowledge taken from the list of ‘do not use’ abbreviations showed that 89.6% reported using ‘Q.D.’ instead of ‘once a day’, and 93% used ‘IU’ instead of the entire phrase ‘international unit’. The top five ‘not to use’ abbreviations were ZnSO4, µg, MgSO4, IU and SC, with the frequency 100%, 96%, 94.8%, 93% and 90%, respectively.

Conclusions

This study showed that there is a knowledge gap among trainees in medicine regarding the meaning and usage of common medical abbreviations. We therefore recommend proper education of trainees in medicine to ensure they understand the meaning of abbreviations and are aware of the list of ‘do not use’ abbreviations.

]]>2016-11-23T22:44:25-08:00info:doi/10.1136/postgradmedj-2016-134086hwp:master-id:postgradmedj;postgradmedj-2016-134086The Fellowship of Postgraduate Medicine2016-12-01Original article921094721725http://pmj.bmj.com/cgi/content/short/92/1094/726?rss=1
An estimated 5.1 million Americans have chronic heart failure and this is expected to increase 25% by 2030. Heart failure is a clinical syndrome that evolves from either functional or structural changes to the ventricles that lead to filling or ejection abnormalities. Thus far, pharmacotherapy has been show to be beneficial in patients only with reduced ejection fraction; however, new therapies have been developed in hopes of reducing the burden of heart failure. In this review, we will discuss current pharmacotherapies recommended in American College of Cardiology/American Heart Association guidelines, the evidence behind these recommendations as well as new and emerging therapies that have been developed.
]]>2016-11-23T22:44:25-08:00info:doi/10.1136/postgradmedj-2016-134378hwp:master-id:postgradmedj;postgradmedj-2016-134378The Fellowship of Postgraduate Medicine2016-12-01Reviews921094726734http://pmj.bmj.com/cgi/content/short/92/1094/735?rss=1
Medical registrars have been described as the ‘workhorses’ of National Health Service hospitals, being at the interface of acute and chronic health services. They are expected to demonstrate effective leadership skills. There are concerns from the Royal College of Physicians that medical registrars are being overwhelmed and unsupported by organisations, and are struggling in their ability to provide safe, high-quality patient care. Junior colleagues are also being deterred by general medical specialties by the prospect of becoming the ‘Med Reg’. There is a growing need to support medical registrars in several key aspects of training, not least medical leadership. Thus far, there has been a distinct disparity in the provision of medical leadership training for junior doctors in the UK that has adversely affected the standard of care given to patients. Recent landmark reviews and initiatives, principally the Medical Leadership Competency Framework, have raised awareness of leadership competencies for all doctors and the need for their incorporation into undergraduate and postgraduate curricula. It is hoped that interactive strategies to engage medical registrars in leadership training will lead to positive results including improvements in interdisciplinary communication, patient outcomes and fulfilment of curriculum competencies. Organisations have a duty to improve the quality of medical leadership training so that doctors feel equipped to influence change throughout their careers and be tomorrow's leaders. This review outlines the deficiencies in training, the importance of developing leadership skills in medical registrars and educational strategies that could be implemented by organisations in a cost-effective manner.
]]>2016-11-23T22:44:25-08:00info:doi/10.1136/postgradmedj-2016-134262hwp:master-id:postgradmedj;postgradmedj-2016-134262The Fellowship of Postgraduate Medicine2016-12-01Reviews921094735740http://pmj.bmj.com/cgi/content/short/92/1094/741?rss=1
Case presentation

A 43-year-old Caucasian female patient was admitted to the emergency department with chest pain and dysphagia for solids and liquids. Symptoms began after she took clindamycin 300 mg orally for one day and had been worsening for 24 h before she came to hospital. A constant, squeezing pain had started behind her breastbone, spreading to the upper stomach and back and was worsened by swallowing and movement. No nausea, vomiting, dyspnoea or fever was observed. Clindamycin had been prescribed as an antimicrobial prophylaxis before oral surgery (apicoectomy). The patient's past medical history was unremarkable. Pharmacological treatment, except for clindamycin and allergies, was negative. On admission, the patient was afebrile, normotensive and eupnoeic at rest. Her physical examination revealed no signs of cardiac decompensation, bleeding, pulmonary disease or any other life-threatening condition. The results of an ECG, complete blood count, C-reactive protein, electrolytes and troponin T were within normal...]]>

Recruitment into core medical training has declined over the last decade, leading to job vacancies across the UK in all training grades.12 The aim of this single-centre study is to identify the reasons why trainees choose alternative career paths and highlight areas that could be improved upon to promote recruitment.

Methods

A survey was emailed from February to March 2016 to foundation trainees, core medical trainees, medical specialty registrars (StR) and ACCS/ITU/AE (acute specialties) trainees and GP trainees who had undertaken a period of general internal medical training in a large district general hospital in South Wales.

2016-11-23T22:44:25-08:00info:doi/10.1136/postgradmedj-2016-134445hwp:master-id:postgradmedj;postgradmedj-2016-134445The Fellowship of Postgraduate Medicine2016-12-01Letter921094742742http://pmj.bmj.com/cgi/content/short/92/1094/743?rss=1
Progressive supranuclear palsy (PSP) is a neurodegenerative disease caused by tau protein accumulation. It is also classified as an atypical parkinsonian syndrome. The main features of PSP are recurrent falling and vertical gaze palsy. Other manifestations are bradykinesia, cognitive dysfunction, erect posture, dysphagia and dysarthria.1

The brain MRI of patients with PSP shows significant atrophy of the midbrain with decreased midbrain-to-pontine anteroposterior diameter on the sagittal plane. There is also flattening or concavity of the upper surface of the midbrain. These changes cause a special picture of the midbrain, which is called ‘hummingbird sign’.2

Here we present an online of a patient with PSP which shows vertical gaze palsy to command, but normal vertical gaze with oculocephalic manoeuvre. This highlights the supranuclear nature of gaze palsy. The brain MRI shows a typical hummingbird view on the sagittal T2 sequence (figure 1).

2016-11-23T22:44:25-08:00info:doi/10.1136/postgradmedj-2016-134082hwp:master-id:postgradmedj;postgradmedj-2016-134082The Fellowship of Postgraduate Medicine2016-12-01Images in medicine921094743743http://pmj.bmj.com/cgi/content/short/92/1094/744?rss=1
A 28-year-old woman presented with sudden onset dyspnoea, left-sided chest pain and dry cough for 3 days. She was a non-smoker. Her blood pressure was 90/60 mm Hg; respiratory rate, 20 breaths/min; finger pulse oximetry, 95% on 10 L/min; supplemental oxygen via non-rebreather mask and heart rate, 100 bpm. On chest auscultation, air entry was absent bilaterally. Initial chest X-ray showed ‘bilateral’ pneumothoraces, left more than right (figure 1). Tube thoracotomy was performed on the left pleural space, with complete resolution of left pneumothorax and partial resolution of right pneumothorax. Contrast-enhanced CT of chest revealed anterior herniation of left upper lobe into the anterior right hemithorax, with the left upper lobe apical subpleural bullae on the right hemithorax (figure 2). The anterior mediastinal septum formed by the apposition of right and left pleura was absent. Airspace consolidation was noted in the left lower lobe. The right main bronchus and right main...]]>2016-11-23T22:44:25-08:00info:doi/10.1136/postgradmedj-2016-134151hwp:master-id:postgradmedj;postgradmedj-2016-134151The Fellowship of Postgraduate Medicine2016-12-01Images in medicine921094744746http://pmj.bmj.com/cgi/content/short/92/1094/745?rss=1
Case history

2016-11-23T22:44:25-08:00info:doi/10.1136/postgradmedj-2016-134197hwp:master-id:postgradmedj;postgradmedj-2016-134197The Fellowship of Postgraduate Medicine2016-12-01Images in medicine921094745746http://pmj.bmj.com/cgi/content/short/92/1094/747?rss=1
A 47-year-old man with a history of advanced oesophageal cancer under concurrent chemoradiotherapy treatment (CCRT) presented with a 10-day history of persistent high-spike fever of 39°C with haemoptysis. He had had worsening of his symptoms for 1 month before presentation, with an associated weight loss of 10 kg.

CT imaging of the chest (mediastinal and lung windows) for fever survey showing pulmonary abscess formation with right-side pleural empyema in the right lung field (A) and high suspicion of oesophagobronchial...]]>

2016-11-23T22:44:25-08:00info:doi/10.1136/postgradmedj-2016-134171hwp:master-id:postgradmedj;postgradmedj-2016-134171The Fellowship of Postgraduate Medicine2016-12-01Images in medicine921094747747http://pmj.bmj.com/cgi/content/short/92/1094/748?rss=1
A 68-year-old woman presented to the emergency department with a 2-day history of epigastric pain, radiating to the back. A diagnosis of Crohn’s disease of the colon was made 6 months before the patient's current presentation, for which she was receiving oral 5-aminosalicylic acid. A colonoscopy performed 2 months before admission showed mucosal remission. On examination, the vital signs were normal and there was mild epigastric tenderness. Her serum amylase level was elevated to 581 U/L (normal range 28–100 U/L). Blood levels of calcium, triglycerides, aspartate aminotransferase, alanine aminotransferase, total bilirubin, alkaline phosphatase and IgG4 were normal. The cancer antigen (CA) 19-9 level was 40 U/mL (normal range 0–37). 5-Aminosalicylic acid was discontinued. A CT scan showed focal enlargement of the pancreatic head with ductal dilatation and distal pancreatic atrophy (figure 1). Endoscopic ultrasound revealed a focal, irregular mass, and fine-needle aspiration was negative for malignant cells. At that time, the patient...]]>2016-11-23T22:44:25-08:00info:doi/10.1136/postgradmedj-2016-134237hwp:master-id:postgradmedj;postgradmedj-2016-134237The Fellowship of Postgraduate Medicine2016-12-01Images in medicine921094748749http://pmj.bmj.com/cgi/content/short/92/1094/751?rss=1
If you mention the name William Osler to medical students or young doctors, they will almost certainly associate him with "Osler's nodes" – the painful swellings that occur in infective endocarditis, and which he first identified. Much older doctors are likely to know of Osler mainly as the author of the first modern textbook of medicine. His "Principles and Practice of Medicine," first published in 1892, went through seventeen editions and became the model for all subsequent medical textbooks. However, if you could turn the clock back, and ask anyone trained in medicine before the middle of the twentieth century, you would hear a quite different kind of narrative. It might astound you. Sir William Osler was regarded in his own time as quite simply the greatest physician in the history of the world. This view was held widely: among his patients, medical students and colleagues, and by the...]]>2016-11-23T22:44:25-08:00info:doi/10.1136/postgradmedj-2016-134618hwp:master-id:postgradmedj;postgradmedj-2016-134618The Fellowship of Postgraduate Medicine2016-12-01On reflection921094751752